Behavioral Health - Key Activity 5


Enhance Inreach and Outreach to Engage People in Behavioral Healthcare


This key activity involves the following elements of person-centered population-based care: proactive patient outreach and engagement; behavioral health integration.


Inreach means to do outreach to patients already within the practice. Most IBH departments in community clinic settings see less than 10% of total patients, marking a significant gap between those who need and those engaged in behavioral health care. Most practices have thousands of patients who are struggling with behavioral health symptoms and are not engaged in behavioral healthcare. Clearly communicating to patients within the organization about behavioral health conditions and the availability of BH services can help connect patients to needed treatment. Successful inreach uses language and media that reflects the preferences of different populations served by the practice.

Outreach is connecting outside of the organization and the practice’s established patients to engage people with behavioral health needs in care. This is typically done in partnership with other community agencies, schools, emergency departments and other organizations.

Practices can begin by enhancing and expanding inreach to engage more of their established population with behavioral health needs in care. As capacity grows, practices can work with partner organizations to expand outreach activities. Note that engaging in inreach or outreach strategies is only feasible when there is behavioral health capacity to offer patients; see Key Activity 4: Develop Strategies to Maximize Capacity of IBH Services.

One of the distinguishing factors between population behavioral health and usual care is the commitment to providing care and services to those not already engaged. Population behavioral health takes into account all patients in the organization (inreach) and all people in the community (outreach), assesses how many people need behavioral healthcare, and develops strategies to proactively engage people in care.

Inreach and outreach are informed by a variety of data and information sources and do not rely solely on individual referrals. Using secondary data sources, existing community assessments, and information from partner organizations (outreach) and data from the EHR and the local health plans (inreach), the practice will be able to identify, prioritize, and implement meaningful interventions to engage patients in behavioral healthcare.

Proactive inreach and outreach, when intentionally focused on communities that have experienced racism, bias and discrimination, is a crucial intervention to eliminate health inequities. Through inreach and outreach, organizations can develop specific strategies to engage particular groups or communities by providing information and a welcoming environment to patients of historically underserved and under-resourced groups inside and outside the practice. This is best done in collaboration with staff (inreach) and community partners (outreach) who are representative of and trusted by the community.

Health-related social needs (e.g., income insecurity, transportation issues, and health literacy) can result in no-shows and deterioration of patient health status. Proactive inreach and outreach, coupled with awareness of health-related social needs, can facilitate connecting patients to community resources and developing greater trust in the care team.

Recognizing that trauma and its sources can lead to lower engagement, consider identifying a staff member or peer leader who is very skilled in empathic listening to reach out to patients to learn what gets in the way of engaging in behavioral health services, as well as the supports that they would most appreciate and would be most effective. This could be through email or text, phone, in-person conversation, or in focus groups. Health centers have different care team members fill this role, including community health workers, health educators, medical assistants, medical social workers, care coordinators and managers.

This activity relies on similar capabilities as care gap management, utilizing population views and registries to identify patients who would benefit from behavioral health engagement. These registries can be utilized to generate inreach and outreach lists for care team members who might be tasked with engaging patients in behavioral health services. Many EHRs can store next-appointment data that can also be used to generate lists supporting these efforts. In addition, EHR alerts and prompts can be leveraged to identify patients for engagement. Care managers and/or behavioral health team members might use care management applications to document engagement efforts.

Other relevant HIT capabilities to support this activity include clinical decision support and communication platforms, such as texting. Some health centers may focus extra resources on patients identified as having elevated risk through risk stratification algorithms.

See Appendix D: Guidance on Technological Interventions.

Action steps and roles

1. Understand the behavioral healthcare needs of the practice’s patients and community patients.

Suggested team member(s) responsible: Population health staff, data analyst, clinical leaders.

  • Inreach: Mine practice data and local health plan data to better understand health inequities, patterns of use, and unmet needs of the practice’s population. The following suggestions are potential options for analysis and over time your team will determine which data sources illuminate your patient population’s health inequities, using patterns and unmet needs.
    • Review practice data for opportunities to improve BH engagement for existing patients. Data of particular interest may include, for example, the number of patients engaged with BH over the last 12 months, by race or ethnicity; the number of patients on psychotropic medications with no behavioral health visits; the percent of postpartum patients engaged in BH in the last year; patients with positive scores on depression, anxiety, ACE and SUD screenings in the last year with no behavioral healthcare; or patients with more than two ER visits in the last year.
    • Partner with local health plans to gather data on the practice’s patient population with regard to BH needs. Examples of BH-related data from health plans include patients’ emergency department usage, hospitalizations, pharmacy claims for opioids or any psychotropic medication, and patients assigned to the practice with no visit in the last year, etc.
  • Outreach: Partner with community leaders, state agencies or professional bodies to obtain data on BH conditions in your area.
    • Initiate or strengthen connections to county behavioral health departments, community-based social needs organizations, schools, hospitals, and faith groups. Let potential partners know that you are interested in improving access to BH services and ask them if they would participate in a conversation with you about what they see as the priority needs in the community. The conversation might start with a simple question like, “In your experience, what BH needs are unmet in your client or patient population?” As the partnership takes shape, establish regular meeting times, communication norms and other relational strategies. Consider business agreements or other formal arrangements to share data.


2. Develop or enhance inreach and outreach to all patients and community members, prioritizing patient preference, dignity, autonomy and readiness.

Suggested team member(s) responsible: Clinical leaders, operation managers, staff.

Inreach strategies include:

  • Develop patient-facing materials in the languages of populations served. Examples include:
    • Posters for the waiting room, which list common BH concerns, BH services at the practice, and how to make an appointment with a BH provider.
    • Pamphlets about high-prevalence BH conditions, such as depression, anxiety, ACEs and SUD; include the practice’s IBH information and how to make an appointment.
    • Text blasts or telephone hold messages that inform patients that BH services are available and how to make an appointment.
  • Develop a list of patients with BH needs using data reports (examples above) from the EHR or the health plan, then assign skillful BH case managers or care coordinators to call patients on the list and offer them BH services.
  • Using data reports, have a medical assistant or other staff add alerts or other prompts within the EHR for patients on the list to indicate to staff and providers to discuss and offer BH services when they next come in for care.
  • Collaborate with leaders and staff in other departments to develop specific inreach strategies for subpopulations with high behavioral health needs (e.g., patients obtaining medication-assisted treatment (MAT) for opioid use disorder, pregnant and postpartum patients, or patients with chronic pain).
  • Develop standardized clinical pathways for subpopulations of focus (e.g., automatic referrals for patients who score positive on BH screening tools, have chronic pain, or with a recent discharge from the ER).
  • Employ inclusive communication methods grounded in cultural humility. Language that is congruent with patient preference is the first step. Utilize EHR data to align the communication method (e.g., call, text, email) with patient preferences.
  • Select staff to carry out inreach based on the strength of the existing relationship with the patient group of focus (e.g., selecting Comprehensive Perinatal Services Program (CPSP) staff for inreach to pregnant and parenting patients; the cultural and language congruence with the patients of focus; and the available time of the staff.
  • Ensure all inreach activities prioritize patient autonomy. Inreach explains BH services and offers BH services; the nature of inreach is supportive, not mandatory.
  • Ensure inreach activities take into account patient preferences. When patients receive care aligned with their preferences – both location and type of treatment – adherence is higher and health outcomes are improved.[1]

Outreach strategies include:

  • Co-designing outreach services with people in the population of focus is a best practice. Engage members of the consumer advisory board and the consumer members of the practice’s own board to co-design outreach methods.
  • Reaching out to leaders who are trusted by the communities that you are trying to engage in care. Ask current patients where they feel supported in the community. Take your outreach to the community by making appearances at churches, schools, community centers, farmer’s markets, food pantries, homeless shelters or other gathering places. Consider deploying community outreach workers to build relationships with potential patients by engaging in their neighborhoods.
  • Deepening relationships with organizations that are part of the provider network in your community. County behavioral health departments, county BH contractors, SUD treatment organizations and housing agencies all likely have clients and patients who need BH services. Develop business agreements, formal referral pathways and informal communication norms.
  • Developing a social media presence for broader community outreach. Consider leveraging staff who are active social media users to help with optimizing your social media presence. Co-design campaigns promoting health and wellness with community partners (e.g., an “It’s OK to not be OK” campaign). Outreach to the community in partnership with community-based organizations may bring new patients to the practice and has the potential of strengthening relationships with community-based organizations that address behavioral or social needs.
  • Focusing outreach to spur referrals by community partners, which requires relationship building. Consider onboarding visits, which can be done as group visits, that welcome new patients to the health center and help develop comfort with accessing the health center, introducing them to their prospective care team members.

Tip: Establish a process for engaging patients assigned to your practice who have not yet been seen by their managed care team. Depending on your agreement with the health plans, it is important for practices to make a proactive plan to build capacity to accommodate assigned-but-not-yet-seen health plan patients in the clinic. Consider developing strategies for outreach and engagement with these populations in order to shift them from not yet seen to fully engaged in primary care, as well as a process for patients not yet seen for whom outreach may be unsuccessful. These patients may be getting their preventive and behavioral healthcare elsewhere though still assigned to the practice.

3. Prioritize inreach and outreach opportunities based on available practice resources.

Suggested team member(s) responsible: All care team members.

For both inreach and outreach, ensure the selected staff, team, or practice champion have the necessary time and support to conduct activities.

Regarding inreach, practices may have significantly more BH needs within the current patient population than resources to meet the needs. In this case, identify a prioritized group for inreach. You may consider subpopulations that align with a focus of other concurrent initiatives (e.g., patients with adverse childhood experiences, if the practice is involved in trauma-informed care (TIC) efforts), groups who have worse health outcomes, or groups whose needs match the practice’s resources (e.g., inreach to those with substance use disorders, if the practice has IBH staff and clinicians who treat SUD).

Regarding outreach, behavioral health needs in the larger community are likely to be significant. Schools, law enforcement systems, social care organizations and other behavioral health agencies are most certainly in need of behavioral healthcare for their patients, students, clients and families. You may already be aware of many pressing BH needs in the community or you may learn about such needs in the process of outreach to partner organizations. The practice may only have resources to work with one population of focus at a time, so building a stepped approach to partnership will conserve resources and allow the team to build on successes.

Implementation tips

An important element of proactive outreach is to strengthen relationships with community partners. Building trust and mutual understanding is essential and takes time, and there are ups and downs as organizations, staff and leaders change. There is no shortcut to building trust and shared goals. After one or several meetings, and maybe a false start or two, the focus can center on collaborative projects. See more about going deeper with Key Activity 18: Strengthen Community Partnerships.


  1. Street RL, Elwyn G, Epstein RM. Patient preferences and healthcare outcomes: An ecological perspective. Expert Review of Pharmacoeconomics & Outcomes Research. 2012 Apr;12(2):167–80. doi:10.1586/erp.12.3